, Y H o c T P . H b C h i M i n h * T a p 18-^ s b i * 2014 N g h i e n c i m Y h o c •
KET QUA DIEU TRI PHAU THUAT UNG THU' DAI TRlTC TRANG DI CAN GAN
V6 NgQC Bich*, Nguyin Cao Cuang*.
TOM T A T
Ddt van de: Ung thu dai tncc trdng di can gan Id mgt badi dc tinh co tiin hrgng soiig con rdi xdu Chung toi thuc hien nghien dm ndy nhhm danh gid ket qud dieu hi phdu thugt ung thu dgi tiirc ti-ang di can gan.
Phucmg phdp: Hoi cuu md td.
Muc Heu nghiin dm: l.Khdo sdt ddc diem iam sdng, benh hoc cua UTDTT di can gan. 2.Xdc dmh ti le cdc biai chieng sdm, tie vong dm phdu thugt dieu tii triet de UTDTT di can gan S.Ddnh gid kei qud diiu tii phdu thugt UTDTT di can gan.
Kei qud: Co 93 trudng hgp ung thu dgi tmc ti-dng di can gan dugc dieu tii phdu thugt tgi BV. Binh Dan tie 1/2010 ddi 12/2012. Khodng 11% badi nhan dugc phdu thugt triet deviea cat di can gan vd cdt ung thu did fwc tidng Song thdi v&i thdi gian tdi phdt tiung bhdi Id 26 thdng thai gian s6hg trung binh sau md'ld 35 thdng, ty le bieii didng sam sau mold 40% vd kliong co ti-dng hop ndo ti( vong. neu kliong cdt dugc di can gan thdi gian song tnmg binh chi colO thdng.
Kei ludm Ung thu dgi true ti-dng di can gan dugc phau thugt triet deck di can gan ldm tdng thai gian song^
can cho benli nhdn, doi vdi tiimig hgp kliong cut duac di can gan cb tlie kit hop cdc phuang phdp hiiy u tai cho nhu RFA, tiem mi vdo khot u
Tit khoa: ung thu dgi true tidng di can gan.
A B S T R A C T
THE RESULTS OF SURGICAL TREATMENT OF COLORECTAL CANCER LIVER METASTASES Vo N g o c Bich, N g u y e n C a o Cuong
* Y H o e TP. H o Chi M m h * Vol. 1 8 - N o 1 - 2014: 58 - 61
Background: Coloredal cancer liver metastasis is a malignant disease with very poor survival prognosis. We performed this study to evaluate the results of surgical treatmait of colorectal cancer liver metastasis.
Methods: Retrospective descriptive study.
Purpose: l.Survey of clinical features, patliogenesis of colorectal cancer liver metastases. 2. Determine the rate of early complications, mortality of intensive surgical tieatmait of colorectal cancer liver metastases. 3.
Ei'aluate the residts of surgical tieatment of colorectal cancer liver metastases
Results: 93 cases of coloredal cancer liver metastases zoere treated at Bhih Dan Hospital from 1/2010 to 12/2012 There were 11 % patients wlw liave had coloredal cancer resection and liver resection, have an average recurrence time was 16 months, the median survival time was 35 months, the rate of early postoperative complications was 40 % and no case of death; in inoperable cases the median survival time is about 10 months.
Conclusions: Resection of liver metastases increased the survival time for patients who have coloredal canca- liva- metastases Otherwise bcal tumor ablation (Percutaneous ethanol injection, cryotherapy, Radiofrequaicy ablation) could be used for the unresectable liver metastases.
* Khoa Gan mat Benh vien Binh Dan TpHCM,
Tdc gia hen lac BS.CKII.V6 Ngoc Bich DT 0908274361 Email. bich\-oneoc b\'hdfg!vahoo com
58 Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Y Hpc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014 Nghien cmi Y hpc
Keywords: Coloredal cancer liver metastases D A T V A N D E
Ung thu dai tr^c trang (UTDTT) la mpt trong nhimg ean benh ac tihh phb bien nhat tren toan the gioi. Moi nam, uoc tinh co hon 1.000.0(X) tniong hgp moi mac, khoang 500.(300 benh nhan hi vong toan the gi6i«i. Tan so mac b^nh rat cao 6 Bac My, Tay Au, ^ so thap 6 chau Fhi, ehau A va mpt so nubc Nam My. Ngay nay benh cang CO xu huong tang len 6 cac nuoc dang phat trien.
Rieng tai TpHCM, UTDTT tai diing hang thu ba 6 nam, thii tu 6 nu; la nguyen nhan gay chet nguoi thii hai sau benh tim mgch.
Gan la noi thuong di can nhat ciia ung thu dai tryc trang, gan 50% berih nhan chet \d di can gan. Khoang 25% di can gan phat hien dbng thai, va 30% di can gan tai phat trong khoang 2 nam sau cat ung thu dai tivc trangP*. Trong mpt thbi gian dai, tir nam 1980 tra ve truoc chua cb ghi nhan ve van de dieu trj UTDTT di can gan, b?nh dugc eoi la rat bi quan khbng the dieu tri duoc, du hau sbng con dupe tinh bSng thang, thbi gian song trung binh tCi 11-19 thang"'' va sy sbng con 5 nam gan nhu la con so khbng.
Nhung phat trieh gan day trong tiep can benh UTDTT di can gan la thay doi quan diem dieu tri, nhat la 6 thbi dai "dieu trj da mb thuc".
Vai tro cua phau thuat trong boi canh nay ngay cang tra nen quan trpng ngay ca trong truong hpp benh da hen tnen va di can xa.
Mac du cbn thieu nhieu nhiing Qrdx nghiem lam sang ngau nhien, nhung da eo nhieu nghien cuu hoi cuu va so sanh da cho thay rang cat t)6 dupe di can gem la mpt dieu tri triet de toi can thiet cung cap them su song cbn lau dai. Truoc nam 1992, ti le song cbn 5 nam neii cat duoc di can gan dao dpng tir 20-40%, ^n day co nhimg bao cao tang len gan 60%^', trong truang hop di can mpt not don dpc 6 gan neu eit duge thi ti Ie sbng tren 5 nam co the dat den 70%, trong khi do ton tai lau dai vbi hoa tri lieu la rat hiemf^'.
Vl vay, Chiing toi lam nghien cuu nay nham danh gia ket qua dieu tri phau thugt ung fhu dai true trang di can gan.
PHU'ONG PHAP NGHIEN CUtJ Phuong phap hoi cuu mb ta, tii thang 01/2010 den thang 12/2012 tai benh vien Binh Dan, Thanh phb Ho Chi Minh.
Tieu chuan chpn benh
B?nh nhan dupe ehah doan ung thu dai trpc trang di can gan dong thbi va duoc dieu tri phau thuat tai Benh vien Binh Dan tu 01/01/2010 den 31/12/2012.
Tieu chuui l o ^ trur
- Benh nhan dupe phau thuat cit di can gan tai phat.
- Cac truong hpp UTDTT di can gan co bien chiing: tgi u di can gan hoae tai u nguyen phat.
- Cac truang hpp mat daii se bi loai trong viec danh gia ket qua theo doi song con sau mb.
Chbng chi dinh cat gan theo NCCN*^
- The h'eh gan eon lai khong dii.
- Benh gan man, xo gan.
- Vang da {loai tni vang da do tac mat ngoai gan).
- Thuyen tae, xam lah tmh mgdi cua.
- Di can ngoai gan {ngoai tni cb di can phoi).
KET QUA NGHIEN ClTU
Tu thang 1/2010 den thang 12/2012, ehung toi ghi nhan dupe 93 TH UTDTT di can gan dbng thbi dupe phau thuat tai BV. Binh Dan thoa tieu chuan chpn vao nhom nghien ctiu vbi ket qua nhu sau:
Dac diem lam sang va bpnh hpc Tuoi, gidi tinh
Tubi Toac benh nho nhat la 29 tubi, Ibn nhat la 83. Trung binh la 58,77. Tuoi thuong gap nhat tii 50-59 tuoi chiem 35%, tren 50 tuoi chiem 81%.
Hpi Nghi Khoa Hpc Ky Ihuat BV. Binh Dan 2014
Nghien cuu Y hpc
Nam chiem 61%, nu 39%. Ti Ie nam/nii la 1,58.
Vi tri ung thu dqi true trdng
Trong 93 truong hpp UTDTT di can gan trong n ^ i e n ciiu ciia chiing toi, ung thu true trang chiem b le 55%, dai tirang 44%. Cb mpt truong hpp ung thu ca hai noi tren khung dai trang chiem ti le 1,1%.
Ly do nhap vien
Trieu ehung lam sang thuong gap la di tieu ra mau chiem 50%. Trifu chiing dau bung 33%, va khoang 17% la do co rbi loan thbi quen di cau.
Thai gian khai phdt benh deh khi dugc dieu tri vd yeu to'sut can
Thai gian tir khi tri?u chiing bat thuong den khi dupe chah doan nhieu nliat khoang hi 4-12 tuan chiern ti le 69%, ti 1? benh nhan de benh keo dai man tinh khong dieu tri chiem 14% va co 17% duoc phat hien b^nh rat som.
Trong nghien ciiu cb 65% benh nhan co bieu hi^n sut can, dieu nay cung kha phii hpp vi co 69% b?nh nhan dupe phat hien b?nh tir 4-12 tuan, mbi lien he co y nghia ve mat thong ke (x2
= 4,13 vbi p=0,042< 0,05)
Ve benh ly ngi khoa di kem vd tong trqng benh nhdn truac mo
Vbi tren 90% t)$nh nhan co tong trgng tii trung binh tro len, va mac dii ti 1^ mac benh ly bm mach di kem kha cao trong nghien ciiu ciia ehung toi {da phan la thieii nang vanh chiem ti 1^
44%), nhung ta't ca cac truang hpp deu khong co chbng chi dinh can thiep phau thuat cho dii co su ket hpp cua 2 hay nhieu benh ly npi khoa tren ciing mpt benh nhan.
So'lugng u gan trudc mo, ktch thuac u, di can ngodi gan, do biet hoa te'bdo
10% khong dupe phat hien cb di can gan trube mb (cac truong hpp nay khong dupe lam CT) va tren CT ciing khong phat hi?n di can gan CO 3 truang hop, 62% di can gan hon 2 thiiy, 55%
cb han 2 u di can gan, va 40% di can gan co kich thuoe tir 2-5cm.
Y Hpc TP. Hb Chi M i n h * Tap 18 * Sb 1 * 2014 Di can ngoai gan chiem 34%, trong do chu yeu la di can hach dpc dbng mach chii bung 50%, di can phbi chiem 16%.
Tbn thuong dgi the khi npi soi dgi trang 77%
cb dang choi siii, biet hba te bao cao chi chiem 39%, cbn lai la biet hoa bning binh va kem.
Ket qua phau thuat
11% benh nhan duoc phau thuat triet de cat di can gan, 47% cat u dai true h-ang khong cat duac di can gan, 3% cit u dgi true trang kem chich con ho trp huy u, 39% chi phau thugt lam hau mon nhan tao khbng cit duoc u nguyen phat.
Bien chiing ciia nhbm phau thugt tri^t de la 40%, khbng co truang hpp nao bien chiing la do eat u di can gan, khbng cb tii vong trong nhom nay.
Tir vong ehung cho toan nhbm nghien eiiu la 1%.
Ket qua theo doi sbng con sau mo Thai gian tdi phdt sau mo cua nhom cat
dugc di can gan
Thdi gian tai phat sau mo trung binh la 16 thang, tai phat som nhat la 6 thang sau mb, va lau nhat la 24 thang. Dimg kiem dinh Log-rank, bubc dau Chung toi ehi ghi nhan kieh thubc u di can gan va dp bi?t hoa te bao la hai yeu to c6 li&i quan den thbi gian tai phat sau phau thuat.
Thin gian song con sau mo cua nhom phdu thuat CO cat di can gan
Trung vi thbi gian song cbn aia nhom phau thuat b'ch cue la 35 thang.
Ket thiie thai diem nghien ciiu van con 5 benh nhan song.
Nhu ehiing ta da biet, thbi gjan tai phat sau lan cat u nguyen phat va di can gan dong thbi cang ngan thi hen lupng sbng cbn ciia benh cang rat xau, thuc hien phep kiem tuong quan {Pearson Correlation test) chiing tbi eb k^t qua r
= 0,539 vbi p = 0,212 (0,05-1), deu nay ehung to
Hpi Nghi Khoa Hpc Ky thu?t BV. Binh Dan 2014
Y Hpc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014
benh nhan trong nhbm nghien aiu ciia Chung tbi ciing khong ngogi le.
Bdttg 1:
Nghien ciru Y hpc
Thoi gian theo dot 0-12ttianq 13-24 thang 25-36 thanq Tren 36 thang
Ti 1^ sdng cong don % 100 83,33
41,7 41.7
Bang 2: Theo doi thai gian soiig con ciia mgt so tdc
Tac gia Fong(1999}'='' Choti ( 2 0 0 2 ) " ' Y.Wang{2010)"°'
U u (2007)'"' Chung toi
S d B N
1001 226 293 42 7
Ti l i s6ng con (%) sau 1 nam
89 93 58 91 83
3 nam 57 57 26 54 42
5 nam 37 40 11 37
Thoi gian S d n g T B
4 2 46
49 35
Nhu vay, ket qua bubc dau ciia Chung toi ding gan giong mpt so tac gia.
Thbi gian sbng cbn sau mb ciia nhom khbng cat dirpc di can gan
Trung vi thbi gian song con toan bp la 10 thang. Som nhat la 1 thang va lau nhat la 41 thang- Ket thiic thai gian nghien ciiu 15 benh nhan con song va ti le song cpng don sau 3 nam chi con la 3,2%.
Bdng 3.
Khoang thdi gian theo ddi 0-12thSng 13-24 t h a r ^ 25-36 thang Tren 36 th^ng
Ti I f song cdng ddn % 35,7 7,7 3.2 3,2
Theo nghien ciiu dupe thuc hi?n tir 1980- 1990^ tren 484 benh nhan UTDTT di can gan khong dupe dieu tri, thai gian sbng trung binh sau 1 nam, 2 nam, 3 nam, 4 nam tuong ling la 31°o, 7,9%, 2,6% va 0,9%.
KETLUAN
UTDTT di can gan la mbt benh da hen trieh di can xa, tien lupng va du hgu song eon kha ngheo nan. Ngay nay vai nhimg tiiay dbi quan nipm dieu tri, su phat tri&i ciia phuang phap phau thugt ciing nhu gay me hoi siic thi cat dupe dl can gan se cai thien thai gian song cbn to't hon cho benh nhan.
TAI LIEU THAM KHAO
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2 Bem R.\, Abdalla EK.(2CI09), "Curable metastatic cdorectal cancer recommended paradigms", Curr Oncol, pp-200-208 3 Oioti MA, Sitzmann JV, Tlbun MF. et al (2002), "Trends in
long-term survival followmg liver resechon for hq^atic coloTectal metastases" Ann Surg, pp235 759-766 4 Feriay J, Bray F, Pisani P, Parkm DM,(2001), " Career
Inadence, Mortality and Pre\-alence Worldwide", GLOBOCAN ZOOO, Veraon 1.0. lARC Cancer Base No. 5.
Lyon 1AEC2001,
5 Fong Y, Foitner J, Sun RL, et al (1999), "dmical score for predicting recurrence after hepabc resection for metastatic colorectal cancer, analysis of 1001 consecutive cases" Ann Surg. 230, pp309-321.
6 Lau WY, Lai ECH et al (2007), "Hepatic resection bx colorectal liver nnelastases". Smgapore Med, 48(7). pp.635.
7 NCCN Guidelmes v22013 Colon rectal cancer tm wJicOLorp
Nordlinger B, Jaed( D, Guiguet M, VaiUant JC Balladur P, Schaal JC (1992), "Sui^cal resection of hepatic metastases.
Mulbeentnc retrospective study by the French Assoaation of Surger>' In Nordhnger B, Jaeck D 'Treatment of Hepatic Metastases of Colorectal Cancer" Paris Sprmger, pp 129-46.
Eiiers T, Blachrodt RP, (2002), "Treatment fo liver metastases, an update on the posabJihes and results", Eur J Cancer 2002, 38,pp.l023-1033.
Wang Y, Liu YF, Cheng Y, Yi DH, Li P, Song WQ, Fu DL and Wang X (2010), "Prognoas of colorectal cancer with liver metastasis: \*alue of a prognostic mdex", Braz J Med Biol Res, 43(11), pp 1116-1121
Ngdy nlidn bdi bdo: 05/11/2013 Ngdy phdn bien rOian xet bdi bdo 02/12/2013 Ngdy bdi bdo duac ddng 20/02/2014
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
